JOURNAL READING

Negative-Pressure Wound Therapy:

A Comprehensive Review of the Evidence

Presented by:
Siwi Bagus. A

Supervised by:
dr. Galuh Aretnaningtyas Septiani Sp.BP-RE
 ABSTRACT
Background
Negative-pressure wound therapy (NPWT) and its variations are an established adjunctive modality for the treatment
of wounds. Since its introduction, there have been an increasing number of publications with periods of rapid
increases in the number of publications after innovations to the technology. Its application in different wound types
and varying clinical scenarios has also contributed to the growing number of publications.

Methods
A comprehensive literature review (1998–2016) was performed using key words most relevant to NPWT using
PubMed/Medline and OVID. Eligibility criteria included higher level evidence studies.

Results
One thousand three hundred and forty-seven publications werecidentified. A total of 26 publications are included in
this review: 16 comparing NPWT with standard wound dressing, 6 comparing variations of NPWT, and 4 for NPWT
with instillation. The level of evidence, wound type studied, reported outcomes and impact, and key findings are
tabulated and discussed.
Conclusions
The number of publications has grown significantly since the inception of NPWT. In part, this reflects the variations of
NPWT that have developed. However, a greater number of robust, randomized, prospective studies are needed to
support its wide spread use.
 BACKGROUND
Negative-pressure wound therapy (NPWT) is considered a standard
adjunctive treatment option for the management of a variety of wound types
and anatomical locations.
NPWT is a powerful adjunct to surgical management of a wound or can be used in circumstances
where surgery is not possible. Once a wound is clean and well
vascularized, NPWT can expedite healing by secondary intention.
Finally, NPWT optimizes the wound environment through fluid removal with some moisture retention
and reduction of bacterial load. The molecular mechanisms by which NPWT acts on the wound bed
continues to be controversial but is thought to include a modulation of cytokines to an anti-inflammatory
profile and signaling mediated through mechanoreceptors and chemoreceptors. This culminates in
angiogenesis, extracellular matrix remodeling, and finally deposition of granulation tissue.

Type of NPWT: This negative-pressure system can be applied to the open wound bed directly (standard
NPWT or NPWT) or to a closed incision, which is known as incisional NPWT (iNPWT)
 METHODS
A comprehensive search was conducted for indexed published articles extracted from the following
databases:
1. PubMed/Medline and OVID from 1998 to January 2016 by a medical digital information librarian.
2. The following search terms were used: “negative pressure wound therapy,” “negative pressure wound
therapy with instillation,” “negative pressure dressing,” “incisional negative pressure wound therapy,”
and “vacuum pressure dressing.”
3. A review of citations from source documents was completed, and those articles that contained search
terms were also included barring exclusion criteria.
4. All search results were exported to a spreadsheet for organized review. Collected articles were read in
abstract form to screen for the inclusion and exclusion criteria (Table 1)
5. Data items extrapolated from clinical studies included wound type, cohort size, control therapy,
experimental therapy, primary aims, primary outcomes, and summary statement
(Table 2).
METHODS
RESULTS
RESULTS
RESULTS
RESULTS
RESULTS
 DISCUSSION
The prevalence of articles on the topic of NPWT has grown exponentially in the past decade. The first
appreciable raise in publications was in 2007 to 2008 (Fig. 3); this may be related to the pivotal
randomized controlled trial published by Armstrong et al9 on the use of NPWT for partial diabetic
foot amputation in 2005. This contribution to the literature validated the use of NPWT in complex
wounds and opened the door for investigation of this therapy in other surgical specialties. Another
jump in publications occurred in 2015, likely because of the article published by Kim et al29 in 2014
comparing standard NPWT with NPWTi. This article showed improved outcomes and decreased
infected wounds requiring hospitalization being treated with NPWTi.29,30

The global distribution of publications on NPWT is broad and includes many countries that
have contributed less than 10 articles to the literature (Fig. 2). From this, one can gather that
the use of NPWT is widespread internationally, although no article exists discussing the usage
prevalence of NPWT globally. Interestingly, the United States and England have the greatest volume
of literature on the topic, likely reflecting their pervasive use of this therapeutic modality. The use of
this technology in countries with fewer publications cannot be taken at reflect their usage, as this
review was limited to English and Medline indexed articles only.
 DISCUSSION
NPWT has evolved from an inpatient therapy to a portable therapeutic modality and most recently
includes the use of instillation. Throughout the last 10 years, the safety and efficacy of NPWT have
been evaluated in burn patients and trauma patients, along with diabetic and medically complex
patients, in both acute and chronic wounds. There remains some controversy over the use of NPWT
for complicated wounds in diabetic patients. Although several randomized controlled trials showed
superiority of NPWT over standard dressing, Masden et al15 found that NPWT applied over closed
incisions was non superior to standard dressings in reducing infection or reoperation in wounds
belonging to patients with more than 2 comorbidities.

Although the body of literature on NPWT has grown to validate safety and effectiveness in a range of
patient and wound types, there still remain gaps in knowledge. Portable NPWT has only been
evaluated in 2 randomized controlled trials, one presenting equal outcomes to standard NPWT in
noninfected lower extremity diabetic and venous wounds21 and, in contrast, the other stating
superiority of portable NPWT for venous leg ulcers.21,22
 DISCUSSION

Recent studies have shown promising findings for the superiority of NPWTi in infected
wounds.27–30 Unfortunately, 75% of the reported studies were retrospective cohort-
controlled and hold less weight than randomized controlled trials. There is a need
for more prospective randomized controlled trials comparing NPWTi with NPWT and
standard dressing to develop the existing evidence.
CONCLUSIONS

1 NPWT has a role in managing chronic, complex, and infected wounds.

2 Here we cite randomized controlled trials validating superiority of NPWT in certain patient
populations along with some articles that describe equivalency of this therapeutic modality.

3 Clearly, NPWT has changed the approach to the management of wounds.

Technological advances in the interface dressings, occlusive drapes, the user interface, solution
4 delivery, and portability have triggered spikes in the number of publications in the past and will
similarly result in a greater number of future publications.

A concerted effort is needed to publish research focused on identifying the mechanism of action
5
and cost-effectiveness of this technology.
 CRITICAL
APPRAISAL
 The structure and content of journal
The title of the journal

Positive
• Consist of variables studied : yes
• Bold : yes
• No abbreviation : yes
• The structure : <12 words (9)
Negative
-
The author and institution
• Appropriate with the guidelines : yes
 The structure and content of journal

The title of the journal

Positive
• Consist of variables studied : yes
• Bold : yes
• No abbreviation : yes
• The structure : <12 words (9)
Negative
-
The author and institution
• Appropriate with the guidelines : yes
 The structure and content of journal
Abstract
The structure
• consist of 4 parts: background, methods, results, conclusion. There are no key
words
• Informative : yes
• Less than 250 words : yes (186)
Background
• Consist of two paragraph or part : 4 paragraphs
• The first paragraph explain background of the research : yes
• The second paragraph explain hypothesis or objective : no (in first paragraph)
• Less than one page : no (2 page)
 The structure and content of journal
Methods
Design of The Research : Systematic review
• Inclusion and exclusion criteria: mentioned
• Study selection: mentioned
• Analytical studies: mentioned
• Outcome: mentioned

Result
• Characteristic of studies: included
• Accuracy of numeric data: trusted
• Accuracy and compatibility of analytic computer program: trusted
• The result of analysis: included
 The structure and content of journal
Discussion
• The strengths & limitation: was written
• Comparison with other studies: included

Literature
• The structure: appropriate with guidelines
• Appropriate any citation: yes
 PICO Analysis
• Patients with kinds of wound which undergoing NPWT
P therapy

• Type of treatment of NPWT in various journal and

I condition

•-
C

• NPWT has changed the approach to the manage ent of wounds. A

concerted effort is needed to publish research focused on identifying
O the mechanism of action and cost-effectiveness of this technology.
 V I A analysis
VALIDITY
Is the patient allocation randomly conducted in this Yes
study?
Is the patient observation carried out long enough Yes
and complete?

Are all populations in the group randomized, Yes

analyzed?

Do patients and doctors remain blind in the Yes

treatment, apart from the therapy being tested?
V I A analysis
IMPORTANT

Cannot be assessed
 V I A analysis
APPLICABLE
Are there differences in our patients compared to Yes
those in previous studies so that the results cannot be
applied to our patients?
Is the administration of this therapy possible for our Yes
patients?
Does the patient have any beneficial potential if the Yes
above therapy is given?
The therapy study is VALID

The therapy study isn’t IMPORTANT (cannot be

asssessed)

The therapy study is APPLICABLE

 JOURNAL IDENTITY
Negative-Pressure Wound Therapy:
1 Tittle A Comprehensive Review of the Evidence

2 Publication Year 2016

3 Publisher Plastic and Reconstructive Surgery

Ersilia L. Anghel
4 Author
Paul J. Kim